A surgeon who worked at the Department of Veterans Affairs (VA) for decades is alleging that hospital administrators across the country are manipulating statistics on patient mortality rates to increase facility ratings and gain bonuses.
Dr. Michael Mann, a professor of surgery and director of the Cardiothoracic Translational Research Lab at the University of California, San Francisco, told The Daily Caller News Foundation in a wide-ranging interview that he felt compelled to write a book published earlier this year called “Mission Betrayed” on the systemic problems at the VA after he was terminated from the San Francisco VA system in 2011. This termination, Mann says, occurred after he started questioning policies prohibiting surgeries on high-risk patients.
These systemic problems revolve around a system called the National Surgical Quality Improvement Program (NSQIP), which compares patient mortality rates across VA hospitals in the U.S. According to Mann, hospital administrators frequently deny surgery for high-risk patients in order to improve VA mortality statistics. Those statistics are then used to justify bonuses at the local level for those same administrators.
Mann’s background in the VA system is extensive. As a medical student at Stanford in 1990, he began rotating at the Palo Alto VA and spent further time at the facility from 1991 to 1996 as part of his surgical residency. Later, he moved to the San Francisco VA in the early 2000s and became a staff surgeon in cardiac surgery until he was fired in 2011.
Now, years later, he’s coming out to expose statistical manipulation and deep problems at the foundation of the VA.
“The book and my message to the American public really goes way beyond San Francisco,” Mann told TheDCNF. “In fact, if it were just problems in one location, we probably wouldn’t need a book like mine, but the real problem goes to the very heart of the VA as an institution and really calls into question whether the types of reform and the whole approach toward reform that our government seems willing to take at this point is futile–whether it has any hope of really improving the veterans system and whether we really need to look much deeper and ask ourselves much tougher questions.”
While Mann has applauded the VA reforms instituted by President Donald Trump, he believes that a piecemeal approach won’t fix the “fundamental cultural, attitudinal and organizational dysfunction that defines the VA.”
“The problem with the approach that not only Donald Trump, but really all of our government has taken toward the VA in the past decade or so is to address those eruptions at the surface, those things that have broken through what truly is otherwise a façade–very misleading statistics and in many ways intentionally deceptive information about the VA that the VA has learned very masterfully to create this illusion of adequate, if not outstanding, care, so that its status-quo can be unperturbed,” Mann said.
For Mann, this illusion of care has come about because the VA has adapted well to the movement in modern medicine to attempt to quantify care, which is an extraordinarily difficult task. The move to quantify care in the VA came about in 1985. As facility conditions deteriorated, members of Congress passed Public Law 99-166 demanding that the VA compare its surgical mortality statistics to the “prevailing national standard.”
“The VA did an amazing job of measuring its own surgical outcomes, something that had never been done before in such an immense system, but there was no prevailing national standard to be compared to,” he said. “We still don’t really have it for all of surgery, and so the VA instead just compared its own individual institutions within its system and developed something called NSQIP, the National Surgical Quality Improvement Program, and all it really did was rank the hospitals in the VA based on surgical mortality, so one hospital had the lowest mortality and the other end of the spectrum there were hospitals with the highest.”
As Mann notes, mortality rates at VA facilities suddenly began dropping through the floor by close to 50 percent from the mid-to-late 1990s to the mid-to-late 2000s.
“The only way you could’ve rationalized that drop was by saying, ‘Well, the worst institutions were somehow learning from the best institutions,'” Mann said. “But that’s not what happened. Numbers dropped everywhere across the board. There were unprecedented drops of mortality and morbidity. That’s never been seen in any system designed to improve outcomes. There’s no scientific explanation for that.”
Mann said that the numbers across the VA didn’t improve as a matter of coordinated conspiracy, but rather, the technique of manipulating data was learned by osmosis.
“Anybody who’s worked in the VA for any amount of time knows that what people are training to do in the VA—not in a classroom—but just by osmosis is that when the VA asks for something, you make it look good,” Mann said. “All across the country, those VA administrators knew what to do. No one had to tell them. You make it look good. You give central VA in Washington what they want. It doesn’t matter how it affects patients, because that’s not what the central VA cares about. They care about the numbers. They care about how it looks, and so that’s what happened as part of NSQIP.”
Mann told TheDCNF that he also sat through meetings where hospital administrators explicitly told physicians at staff meetings not to bring any high-risk patients into the operating room.
“Even more garden variety lung cancer operations would be labeled high-risk in our patient population,” Mann said. “Ironically, I learned it because they started to put our practice of thoracic surgery under a microscope and eventually they squashed it and got us to stop operating on risky patients and really almost any lung cancer patients at the San Francisco VA.”
“If you were a hospital administrator and you wanted to reduce the number of deaths in your hospital to make your hospital rise in the ranks, no question, you eliminate chest surgeries,” he added. “And just by eliminating chest surgeries, you’re almost guaranteed to rise in the system as long as other hospitals are forced to do that chest surgery that you’re refusing, and that’s basically what happened in San Francisco.”
While Mann emphasized that there are amazing practitioners at the VA, these same practitioners are limited by unnecessary barriers. And the experience of these barriers are so pervasive that according to Mann, “the idea that the VA is a second-rate system for second-class patients is the very first impression medical students get in their training in the United States. And I don’t think that impression ever changes.”
In response to a request for comment regarding the NSQIP system, VA Press Secretary Curt Cashour told TheDCNF, “These are serious allegations. If the doctor can provide evidence, we will look into them.”
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